SUR 122 Genitourinary Surgery Genitourinary System Terminology Anatomy

SUR 122 Genitourinary Surgery Genitourinary System  Terminology  Anatomy

SUR 122 Genitourinary Surgery Genitourinary System Terminology Anatomy & Physiology Pathology Diagnostic & Pre-operative Testing Anesthesia & Medications Basic Instrumentation, Supplies, & Equipment

Incision Site Options Positioning, Prep, & Draping Dressings, Drains, & Post-operative Care Terminology BPH nonmalignant enlargement of prostate common with age Dialysis - waste product removal from the blood of a patient in

renal failure Enucleate remove without cutting into Epispadias urethra terminates on the dorsal surface of penis (on top of) or above clitoris (congenital) Gerotas capsule perirenal fascia that holds kidney in place Impotence inability to achieve erection Hematuria blood in the urine Hilum- everything enters and leaves kidneys through this notch

Ptosis drooping of an organ or part Trigone triangle-like space a bladder base Terminology Hydrocele fluid filled sac in the scrotum Hypospadias urethra opens on ventral surface (underneath) of penis, perineum, or inside the vagina (congenital) Paraphimosis retraction of prepuce results in painful swelling of glans Phimosis uncircumcised male prepuce wont retract

from glans Wilms tumor - malignant neoplasm of a kidney in children 3-4yrs. Anatomy video http://www.youtube.com/watch?v=xYTjvqzyd9 k Male Reproductive System Large part external to body cavity Scrotum=pouch of skin that contains testis

Testis are both endocrine & exocrine glands Exocrine=secrete sperm via ducts Endocrine glands produce testosterone Male Reproductive System Testis Lobules with 3 cell types: 1. Seminiferous tubules involved in spermatogenesis 2. Interstitial cells (cells of Leydig) produce testosterone

3. Seratoli cells provide nutrients for sperm Male Reproductive System Sperm Male produces 300 million sperm per day=120million per ml Less than 20 million per ml considered sterile Male Reproductive System Sperm (3 parts)

2. Midpiece extension that contains large 1. Head amt of mitochondria (ATP) a. Acrosome contains chemical hyaluronidase which is an 3. Flagella enzyme that breaks down hyaluronic acid (found in loose

of aegg protein connective tissue) that allows spermtail to composed penetrate the that allows for movement b. Nucleus (haploid) contains 23 chromosomes (when unites generated total by ATP

with egg also 23 chromosomes, chromosome becomes 46) 1 N Male Hormones 1. FSH Tells interstitial cells to produce testosterone and sperm in testis 2. LH Tells interstitial cells to develop and secrete testosterone

3. Testosterone Stimulates development, growth and maintenance of male reproductive system including sex characteristics, maturation of sperm, and skeletal muscle development Ducts 1. Epididymis Series of ducts or channels that communicate with the testis Store sperm Area for sperm maturation Ciliated columnar cells secrete

2. Vas Deferens Loops up over bladder Transports sperm Ciliated columnar cells and smooth muscle (peristalsis) move sperm 3. Ejaculatory duct Vas deferens merge into this posterior to bladder which merges with the urethra (runs through the prostate) Male Reproductive System Summation Testis are located in the scrotum

Testes produce sperm and testosterone Contain lobules containing seminiferous tubules where sperm arise Lobules lead to ducts in the epididymis Epididymis leads to ductus deferens

Ductus deferens open into urethra Testis suspended by spermatic cord Spermatic cord goes from inguinal ring to testis Inguinal ring also contains ductus deferens, testicular vessels (arterial, venous, and lymphatic), and nerves Accessory Organs 1. 2.

3. Seminal vesicles Behind (posterior) bladder Secrete into ejaculatory duct 60% liquid portion of semen Prostate gland

Donut shaped as urethra runs through it Secretes 30% liquid portion of semen directly into the urethra Bulbourethral (Cowpers) glands 10% volume of semen (lubricates head) Neutralizes acidity of urethra Secrete directly into urethra Internal urinary sphincter tightens w/ejaculation to prevent mixing of urine w/sperm Accessory Organs

Penis 3 cylindrical tissue masses Corpus cavernosum x 2 (upper) Corpus spongiosum x1 (lower) Urethra passes through corpus spongiosum These three areas are surrounded by blood sinuses Arteriole blood retention allows an erection Post-ejaculation pressure is released

Genitourinary System Kidneys Adrenal glands Ureters Urinary Bladder Urethra Prostate Gland (male)

Kidneys Location retroperitoneal At T-12 to L-3 vertebral column Encapsulated in perineal fat and fascia renalis capsule which hold them in position Hilum medial area where renal artery and vein enter and exit

Left larger Right lower due to liver location Functional unit is the nephron: filtration, reabsorption, secretion Nephron > 1 million per kidney 2 types: juxtamedullary and cortical Each composed of capillary network: Renal corpuscle Renal tubule

Nephron Renal Corpuscle: Bowmans Capsule

Glomerulus Renal Tubule: Proximal Convuluted Tubule Loop of Henle Distal Convuluted Tubule Collecting Tubule Renal Corpuscle 1. Filtration Bowmans Capsule (glomerulus encased by) Glomerulus (capillary network) Water and substances filtered from blood

Renal Tubules 2. Reabsorption Substances move from renal tubules into capillaries (blood) surrounding the tubules Prevents needed body substances from being lost in urine Proximal convuluted tubule (origin in Bowmans Capsule) Loop of Henle Distal Convuluted Tubule

Renal Tubules 3. Secretion Substances move from blood into tubules (urine) Distal Collecting Tubule Collecting Tubule

Filtrate/Urine Pathway Fluid once it leaves the blood and is in the nephron called filtrate, once leaves nephron is called urine Nephron > papillary duct > minor and major calyces > renal pelvis > ureters Urinary Bladder

Holds average of 800ml Three layers: Submucosa, Muscularis, Inner Tunica Mucosa Muscularis called detrusor muscle Internal sphincter = smooth muscle = involuntary control External sphincter = skeletal muscle = voluntary control

Stretch receptors in bladder signal brain via micturation reflex About 400ml, brain relaxes internal sphincter This signals you its time to go Inner Tunica mucosa is rugae surface (allows for stretching) except in the trigone area which is a smooth surface Adrenal Glands (Suprarenal) Job to augment the Sympathetic Nervous System division of the Autonomic Nervous System Endocrine glands: contain cortex and

medulla Cortex: secretion of fluid and electrolyte balance controlling steroids and hormones (aldosterone and cortisol) Medulla: produces, stores, & secretes epinephrine (adrenaline) & norepinephrine (noradrenalin) Adrenal gland (cortex) Aldosterone- decreases urine output as it stimulates renal tubules to reabsorb water

and salts (sodium reabsorption) Most active hormone Indirectly regulates: Electrolyte levels (bicarbonate, potassium, chloride) Blood pressure Blood volume pH levels Adrenal gland (cortex) Adrenal gland (cortex) Cortisol (hydrocortisone)

Affects glucose metabolism Regulates metabolism of fats, carbohydrates, proteins, fats, potassium Anti-inflammatory Adrenal gland (medulla) Adrenalin (epinephrine) Constricts visceral vessels Dilates skeletal muscles Dilates bronchiole musculature Increases glucose production

Decreases GI activity Increases heart rate Adrenal gland (medulla) Norepinephrine Increases blood pressure Decreases heart rate Constricts vessels (arterioles and venules) Pathology of the Male Reproductive System

Phimosis Hypospadias/Epispadias BPH Cancer of the Prostate

Cryptorchidism Testicular Torsion Testicular Cancer Trauma Phimosis Foreskin will not retract Congenital Geriatric Can cause infection, pain Tx: circumcision

Hypospadias Epispadias Hypospadias Epispadias Urethral opening under on top the of the penis penis (ventral)

(dorsal) or on the perineum Urethral opening above the clitoris opening inside the vagina Urethral Congenital Congenital Tx: Surgical repair Tx: Surgical repair

Cryptorchidism Failure of testes to descend into scrotum after 1 yr of age Found in abdomen or groin Often seen with inguinal hernia Premature birth Tx: HCG hormone therapy Orchiopexy Orchiectomy

Testicular Torsion Spermatic cord is twisted Tx: Orchiopexy Testicular Cancer 20-40yrs Infants with cryptorchidism higher risk Embarrassment leads to non-treatment which allows progression of disease Tx: Orchiectomy Sperm may be stored

Testicular implants available for cosmetic purposes BPH Hypertrophy Normal part of aging > 50 yrs Urethral narrowing can result Tx: Drug therapy prostate growth (medical) TURP (surgical)

Prostate Cancer > PSA 50 (prostate yrs specific antigen) Normal Asymptomatic value <4ng/mL in early stages of disease PSA

Symptom laboratory of blood testinofthe choice urine,bylikely mentoo over late 50 for early detection

Will be done if BPH detected on digital exam to r/o cancer PSA f/u with biopsy Pathology of the Urinary System Bladder Tumors Urinary Calculi Polycystic Kidney Disease Diabetic Nephropathy ESRD Renal Cell Carcinoma Congenital Nephroblastoma (Wilms Tumor)

Urinary Calculi/Stones

Solid particles that form in one or both kidneys May become lodged Pass < 4mm stones 80% of the time 50% recurrence rate 3 types: Calcium (75%) dietary imbalance/hyperparathyroidism Magnesium ammonium phosphate (struvite) (15%) UTI Uric Acid (6%) associated with gout Cystine amino acid reabsorption failure ESWL Extra-Corporeal Shock-Wave Lithotripsy

Renal Calculi Historical: Done in large tub and patients were intubated and connected to the shock therapy unit Present: Water-bed like unit under lower body. Stone lined up with C-arm machine/cross-sectioned + Stone hit with shock waves precisely

Avoid bone Shocks gauged to match patient HR, otherwise patient can experience arrhythmias if shock wave exceed HR Usually range from 120/min to 60 /min Other Methods of Stone Removal Cystoscopic / ureteroscopic / nephroscopic lithotomy Direct extraction via Laser through Small Lithotripsy unit used through

Percutaneous lithotomy Open lithotomy Polycystic Kidney Disease Multiple fluid filled cysts in parenchyma of kidney One kidney could have thousands Kidney could weigh up to 22lbs. 3 Types: 1. Autosomal dominant (hereditary) 30-50yrs 90% 2. Autosomal recessive (rare/congenital)

Children 3. Acquired (long term kidney problems) Diabetic Neuropathy (sclerosis) Uncontrolled diabetic Progressive disease>ESRD>dialysis ESRD Kidney failure Final stage of many kidney diseases Filtration system in kidney < 10%

50% are diabetics s/sx: UO, BUN and creatinine levels Death imminent without method of waste and fluid removal Tx: Hemodialysis and Peritoneal Dialysis Hemodialysis 1.

2. 2 Vascular lumens: one access for outflow and one for inflow

Dialysis Temporary machine has 2 compartments: one for incoming blood and one for dialysate Dual lumen catheter (Vas Cath) Between compartments is a semi-permeable membrane that Permanent

filters like thegraft kidney PTFE loop Excess wastes fluids go into and dialysate aremost

disposed of Creation of AVand fistula (cephalic radialand artery Important common)blood components and proteins return to body Must mature, so will likely have Vas Cath placed Peritoneal Dialysis

Requires implantation of catheter into peritoneal cavity (ex. Tenckhoff) Allows for infusion of dialysate which draws out waste and fluids After proper amount of time, dialysate and fluid/wastes are drained into a bag Peritoneum serves as filter Pathology Affecting the Adrenal Glands Cushings Syndrome

Addisons Disease Pheochromocytoma Pathology of the Adrenal Glands Cushings Syndrome Overproduction of cortisol Cortisol production: Pituitary gland which stimulates ACTH (adrenal cortical trophic hormone) which stimulates cortisol production Caused by: (80%) pituitary tumor or (20%) adrenal cortex tumor s/sx: HTN, central body obesity, hirsutism, osteoporosis, kidney stones, emotional instability, abnormal menses

Tx: surgical removal of tumor Pathology of the Adrenal Glands Addisons Disease (Adrenal Insufficiency) Hormones needed to maintain fluid and electrolyte balance, blood pressure, and a normal stress response are inhibited

s/sx: weight loss, weakness, fatigue, GI disturbances, low BP, darkening of skin, hair loss, mood/behavior changes Tx: medical hormone replacement therapy Pathology of the Adrenal Glands Pheochromocytoma Overproduction of adrenaline Caused by tumor of the medulla Excessive adrenaline creates severe hypertension s/sx: HTN, severe headache, excessive sweating, tachycardia, palpitations, anxiety, tremors, epigastric

pain, weight loss, heat intolerance Tx: surgical removal of tumor Genitourinary System Reproductive Organs: Female

Pathology of Female Genitourinary and Reproductive System Benign Cysts

Polyps (pedunculated lesion) Fistulas Dysplasia Leiomyoma/Myoma/Fibroid Fibroma

Malignant Vulvar Vaginal Cervical Uterine Ovarian

Other Endometriosis Cystocele Rectocele (posterior colporrhaphy) Enterocele Ectopic Pregnancy Incompetent Cervix (cerclage)

Pre-operative & Diagnostic Testing

H&P UA Hematology: CBC & HGB/HCT Blood Chemistry: Blood Urea Nitrogen and Creatinine KUB IVP Cystogram Urethrogram Cystoscopy CT

MRI Biopsy Incisional Approaches Inguinal Scrotal Abdominal Thoracoabdominal pg. 603 Alexanders Gibson pg. 755 Caruthers Flank pg. pg. 603 Alexanders (more oblique) Lumbar pg. 603 Alexanders (more vertical)

*Provide best exposure Anesthesia General Spinal Epidural MAC with Local Medications Antibiotics Contrast Media (Hypaque) Dyes (Methylene Blue, Indigo Carmine)

Diuretics Instruments Major Set Vascular Tray or CV Tray Extra Long Instrument Set Self-Retaining Abdominal Retractor Chest Tray: Finochetti, periosteotome, Doyan, rib shears, rongeur, Bailey rib approximator Special: Mixters, Potts scissors, Vascular instruments, Bladder & Prostate retractors,

Pedicle clamps, Stone/lithotomy forceps Other Cystoscope Components Bridges (short and long) Cystoscopes: 12, 30, and 70 Supplies Ureteral sounds (dilators) Flexible endoscope and accessories Rigid endoscope instrumentation Resectoscope Ellik evacuator

Toomey irrigator/syringe Accessories: light cord, camera, insufflation tubing, irrigation fluid Irrigations 1. 2.

3. Glycine TURP Water Laser NS Cystograms Supplies Continued Lubricant

Foley catheter and drainage bag Alternative catheters (difficult insertion) Catheter guide (facilitates insertion) Urethral catheters Ureteral drainage bag(s) Catheters Urethral Lumen Size range 8-30 French Ureteral Lumen Size range 3-14 French FYI: Divide French by 3 to get diameter of

lumen in mm Ex: 12 French catheter divided by 3 = 4mm in diameter Equipment OR Table with Foot Drop (lithotomy) & Radiographic

Capability Lead Aprons, Accessories Quick Access to X-ray Development Room IV Poles that will hold heavy fluid bags Sitting stool Multiple X-ray view boxes Video Tower (light source, camera box, insufflator) Cautery with bipolar capability

Positioning Lithotomy Supine Lateral Variations of Above Prep Area of Involvement Begin at incision site and work way out Prep genital area last May not do a prep if urethral approach

Draping Laparotomy Universal Perineal Combination Laparotomy/Perineal Surgeons preference/approach Depends on position Dressings Abdominal: steri-strips, telfa, xeroflo, 4x4s, ABD (surgeons preference)

Vaginal packing Peri-pad Net panties Drains JP Snyder Hemovac/Grenade Penrose Depends on location of surgical wound and surgeon preference

Post-operative Care

Discharge same day to 5 days hospitalization Early ambulation TED hose Turn/cough/deep breath Drink plenty of fluids Avoid heavy lifting >10lbs. at least 6 weeks urine may be pink tinged to red/should clear in few days S/X Infection: incision red, warm, painful, purulent drainage S/SX UTI: fever, chills, hematuria, flank pain, sudden increase in urinary output Complications

Infection Nicking ureters, bladder, urethra, reproductive organs Hemorrhage (major blood vessel proximity) Adhesions Sciatic nerve damage due to spinal placement Blood clot (thrombosis) DVT PE (pulmonary embolus) Summary

Terminology Anatomy & Physiology Pathology Diagnostic & Pre-operative Testing

Anesthesia & Medications Basic Instrumentation, Supplies, & Equipment Incision Site Options Positioning, Prep, & Draping Dressings, Drains, & Post-operative Care

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